Provider Demographics
NPI:1790029742
Name:VIVIAN EKEMEZIE, O.D
Entity Type:Organization
Organization Name:VIVIAN EKEMEZIE, O.D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:OWANIMEDU
Authorized Official - Last Name:EKEMEZIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-843-7153
Mailing Address - Street 1:1036 97TH LN NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3515
Mailing Address - Country:US
Mailing Address - Phone:763-843-7153
Mailing Address - Fax:
Practice Address - Street 1:215 BALSAM ST N
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-5814
Practice Address - Country:US
Practice Address - Phone:763-689-5576
Practice Address - Fax:763-689-3792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3311152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1194070490OtherNPI 1
MN1790029742OtherNPI 2
MN410003852OtherMEDICARE PTAN